Creating tools to improve opportunities for shared decision making during pregnancy

My research in nursing and midwifery has been shaped by a firm belief that all people should have the opportunity to make informed and supported choices about their healthcare, using the best available evidence. I began my research career in the 1990s when I conducted an economic evaluation of a new midwifery early discharge program at my local hospital, where I was practicing as a midwife.1 As a young midwife studying for my Masters degree I became interested in identifying which models of healthcare provided the best outcomes for pregnant women.

At the time I was curious about large and unexplained variations in Australian obstetric interventions and birth outcomes for women. I found that birth experience and mode of birth depends greatly on health insurance, where women give birth and what type of healthcare professional they choose to provide their care. My colleagues and I examined data that had been collected routinely by midwives for every birth in New South Wales over a 10 year period. From these records we were able to discover that hospital funding models (public or private), provider type (midwife or obstetrician), and models of care were the strongest predictors of interventions and outcomes for birth, even when medical risk factors were considered.2-5 I was hooked on data and the power of gathering evidence to tell the story of healthcare.

The systematic search for the best quality evidence to inform pregnancy care quickly became a way of life. As an educator, the next logical step for my work was to find better ways to translate and share new evidence about birth options with women and families, so they could make birth decisions that were best for them.

Birth Choices after Cesarean Decision Aid: The evidence I had gathered about obstetric and midwifery practices in the Australian healthcare system, combined with my midwifery philosophy of promoting physiological birth, motivated me to explore how to support women as they gather knowledge about the risks and benefits of their options and participate in decision making during pregnancy. Childbirth trends in Australia around that time mirrored the United States, with rising caesarean section rates and declining opportunities for women to attempt vaginal birth after previous caesarean (VBAC). This was despite evidence from research that VBAC was safe for most women, with advantages over repeated caesarean surgery. I had completed a cost-effectiveness analysis of trial of labour versus elective repeat caesarean and found important financial advantages in supportive VBAC policies as well.6 Promoting VBAC as a viable option for women became an important motivator for me to help address gaps between evidence and practice in pregnancy care. A multi-faceted approach was clearly necessary to change routine practice. For my PhD I focused on the question of whether improvements in women’s knowledge about birth options could influence their choices and outcomes. Utilizing the Ottawa Decision Support Framework (DSF), I developed the first decision aid booklet for pregnant women who had experienced previous cesarean birth and called it Birth Choices.7 My goal was to inform women about their birth options, and support them in identifying their values and preferences in the decision making process. I designed and conducted a multi-site randomized controlled trial (RCT), funded by a Medical Benefits Fund grant.

Through this work I discovered that my decision aid booklet improved women’s knowledge about their options, which also resulted in less decision conflict.8 The decision aid is listed in the International Inventory of Patient Decision Aids, has been internationally validated in studies to standardize decision aids, and is featured in international systematic reviews of patient decision aids. The Birth Choices decision aid has been updated and is still used in clinical practice, which is the most exciting part of research for me. So far it has been translated into French, Japanese, and Spanish, and adapted for a study in New Zealand. A Chinese translation is currently underway.

Shared Decision Making and Health Information Technology: While my previous research found that decision aids were effective in preparing women for making decisions during pregnancy, one of the critical discoveries was that despite decision aid effectiveness, method of birth was highly influenced by organisational factors within pregnancy care services.13 I was back to the powerful effect of where women chose to give birth (which hospital or health service) and who provided their care. The next phase of my research has focused on exploring new ways to overcome organisational and cultural barriers to shared decision making (SDM), in diverse pregnancy care settings. Over the last three years I have been leading a multi-disciplinary team of US researchers with expertise in midwifery, obstetrics, psychology, decision science and health information technology (IT) to identify innovative approaches to combine decision aids for women with shared decision making in busy, urban ethnically diverse clinical settings.

Our research team received funding from the Agency for Healthcare Research and Quality (AHRQ) in 2013 for a feasibility study “Using Interactive Health IT to Support Women’s Choices for Birth after Cesarean” 1R21HS022114-01. Phase one engaged targeted users (women and providers) in an instructional design process, to translate my original paper-based tool into an interactive web-based format for ethnically diverse groups of women.10 Phase two (in progress) involves a feasibility study of the process of integrating the Birth Choices decision aid into busy urban outpatient clinics within the Yale New Haven Hospital (YNHH) system. We are working to fill a gap in knowledge about integrating web-based decision aids into busy clinical practice environments. Our next steps will be towards identifying the best ways to implement decision aids in practice using a SDM framework, with the goal of maintaining the practice change.

Research has become a way of life. After more than 20 years in academic life it is still exciting to plan new projects and uncover new evidence to inform our practice, with the enduring commitment to improving patient experiences and outcomes.

Allison Shorten PhD RN RM FACM

Associate Professor

Yale University School of Nursing



1.     Shorten, A. (1995). Obstetric early discharge versus traditional hospital stay: Analysing the cost of postnatal care. Australian Health Review, 18(2), 19-39.

2.     Shorten, A., Shorten, B. (1999) Episiotomy in NSW hospitals 1993-1996:  Towards understanding variations between public and private hospitals. Australian Health Review, 21(1), 18-32.

3.     Shorten, A., Shorten, B. (2000) Women’s choice? The impact of private health insurance on episiotomy rates in Australian hospitals. Midwifery, 16, 204-212.

4.     Shorten, B., Shorten, A. (2004) Impact of private health insurance incentives on obstetric outcomes in NSW hospitals. Australian Health Review, 27(1), 27-38.

5.     Shorten, A., Shorten, B. (2007) What happens when a private hospital comes to town? The impact of the ‘public’ to ‘private’ hospital shift on regional birthing outcomes. Women and Birth, 20(2), 49-55.

6.     Shorten, A, Lewis, D.E., Shorten, B. (1998) Trial of labour versus elective repeat caesarean section: A cost-effectiveness analysis. Australian Health Review, 21(1), 8-28.

7.     Shorten, A. (2000) Birth Choices: What is best for you…vaginal or caesarean birth. A decision-aid for women making choices about birth after caesarean section. UOW Printery. Wollongong.

8.     Shorten, A., Shorten, B., Keogh, J., West, S., Morris, J. (2005) Making choices for childbirth: A randomized controlled trial of a decision-aid for informed birth after cesarean. Birth , 32(4), 253-262 .

9.     Shorten, A., Fagerlin, A., Illuzzi, J., Kennedy H.P., Lakehomer, H., Pettker, C., Saran, A., Witteman, H.,   Whittemore R., (2015) Developing an Internet-based decision aid for women choosing between vaginal birth after cesarean and repeat cesarean birth, Journal of Midwifery and Women’s Health. (Early View 8 JUN 2015 | DOI: 10.1111/jmwh.12298


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